A 33-year-old woman presented to the emergency department after being struck behind the right ear by a flying baseball bat at a baseball game. She reported pain, tinnitus, dizziness, and slurred speech but denied loss of consciousness or nausea. Examination revealed right facial motor weakness, tenderness over the right mastoid bone, and right hemotympanum. CT scan showed a transverse temporal bone fracture and air in the internal auditory canal, consistent with a basilar skull fracture.

2.  33 YOF brought in by
EMS after attending a
high school baseball
game, and being struck
behind the right ear by a
flying baseball bat while
sitting in the stands. She
c/o pain behind R ear,
tinnitus, dizziness, and
slurred speech. Denies
LOC, N/V.
 AFVSS
 Gen: WDWN, A&Ox4
 HEENT: NC/AT, PERRL,
EOMi, nml bilat visual
acuity, bilat TMs intact,
right hemotympanum,
right facial motor
weakness, TTP right
mastoid w/o
retroauricular ecchymosis
 Neuro: GCS-14 (Eyes 3),
nml sensation x 4, 5/5
motor strength x 4

4. 1. Air in Internal Auditory
Canal (thin arrow).
2. Transverse temporal bone
fracture (thick arrow).
3. Normal suture line
between temporal and
occipital bones.

5.  Non contrast CT head:
 necessary for suspected basilar skull fx.
 r/o TBI, intracranial bleeds
 +/- Prophylactic antibiotics for CSF rhinorrhea/otorrhea:
 should be done in consultation with Neurosurgery/ENT as
most CSF leaks will resolve spontaneously in one week w/o
complications
 if patient presents 1 wk s/p CSF leak with fever, Abx are
warranted, along with meningitis work-up (LP included)
 Broad coverage Abx w good penetration into meninges, eg.
Ceftriaxone, Vancomycin IV
 Tetanus prophylaxis
 Neurosurgery/Otolaryngology consultation

6.  Signs/symptoms of Basilar Skull Fracture:
Blood in ear canal
Hemotympanum
Rhinorrhea/Otorrhea
Battle's sign (retroauricular hematoma)
Raccoon sign (periorbital ecchymosis)
 Cranial nerve deficits
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Facial paralysis
Decreased auditory acuity
Dizziness/Vertigo
Tinnitus
Nystagmus

7.  Most basilar skull fractures (BSF) involve petrous portion
of temporal bone, external auditory canal and TM, but may
occur anywhere from cribriform plate to occipital condyle.
 Torn dura leads to otorrhea/rhinorrhea
 May be only sign of basilar skull fracture
 Perform and document thorough HEENT exam
 BSF may be subtle on CT scan
 Look for air/fluid levels in sinuses; pneumocephalus suggests
open fx
 Periorbital and mastoid ecchymoses develop slowly (up to
12-24 hours s/p injury), and often absent in ED.

8. Battle’s Sign
(retroauricular
ecchymosis)
Raccoon’s Sign
(periorbital ecchymoses)
Hemotympanum

9.  http://www.Cybermedicine2000.com
 Knoop KJ, Stack LB, Storrow AB, Thurman RJ: The Atlas of
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Emergency Medicine, 3rd ed: http://www.accessmedicine.com
Marx: Rosen’s Emergency Medicine, 7th ed. Ch 38: Head Injury
Ratilal B, Costa J, Sampaio C. Antibiotic prophylaxis for
preventing meningitis in patients with basilar skull fractures.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004884
Schwartz DT: Emergency Radiology: Case Studies:
http://www.accessemergencymedicine.com
Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,
7th ed. Chapter 254: Head Trauma in Adults and Children